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  1. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest | PSNet

    psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
    April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest Citation Text: Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…

  2. Physical Diagnosis: A Lost Art? | PSNet

    psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
    January 17, 2018 - SPOTLIGHT CASE Physical Diagnosis: A Lost Art? Citation Text: Thompson GR, Verghese A. Physical Diagnosis: A Lost Art?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Schola…

  3. Bad Writing, Wrong Medication | PSNet

    psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
    March 01, 2015 - SPOTLIGHT CASE Bad Writing, Wrong Medication Citation Text: Devine B. Bad Writing, Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49744/psn-pdf
    October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy October 1, 2015 Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…

  5. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…

  6. Chest Pain in a Rural Hospital | PSNet

    psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
    June 02, 2021 - SPOTLIGHT CASE Chest Pain in a Rural Hospital Citation Text: MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar Bi…

  7. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. | PSNet

    psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
    September 25, 2019 - SPOTLIGHT CASE Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. Citation Text: Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research …

  8. Airway Obstruction during Anterior Cervical Spine Surgery | PSNet

    psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
    January 29, 2021 - Airway Obstruction during Anterior Cervical Spine Surgery Citation Text: Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …

  9. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy | PSNet

    psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
    April 08, 2019 - SPOTLIGHT CASE The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy Citation Text: Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcar…

  10. Anchoring Bias With Critical Implications | PSNet

    psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
    June 15, 2022 - SPOTLIGHT CASE Anchoring Bias With Critical Implications Citation Text: Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google…

  11. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy | PSNet

    psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
    September 30, 2020 - SPOTLIGHT CASE Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Citation Text: Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. Rockville (MD): Agency for Healt…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49831/psn-pdf
    June 01, 2018 - Chest Pain in a Rural Hospital June 1, 2018 MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/chest-pain-rural-hospital Case Objectives Recognize that a significant proportion of the Unites States population receives care in rural safety net emergency dep…

  13. Suicidal Ideation in the Family Medicine Clinic | PSNet

    psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
    October 01, 2007 - SPOTLIGHT CASE Suicidal Ideation in the Family Medicine Clinic Citation Text: Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49717/psn-pdf
    September 01, 2014 - A Lot of Pain (Medications) September 1, 2014 Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/lot-pain-medications Case Objectives Appreciate the challenges of managing acute pain in hospitalized patients on chronic opioids. Describe the importance of understanding th…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49721/psn-pdf
    December 01, 2014 - Ebola: Are We Ready? December 1, 2014 Barsuk JH, Barnard C. Ebola: Are We Ready? PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/ebola-are-we-ready The Case A 28-year-old man, well-appearing but pale, walked into the emergency department (ED) on a Wednesday afternoon at 3 PM complaining of nausea, vomiting,…

  16. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care | PSNet

    psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
    June 01, 2003 - SPOTLIGHT CASE Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care Citation Text: Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866261/psn-pdf
    July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery July 10, 2024 Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867850/psn-pdf
    February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/persp…

  19. The Deadly Duo | PSNet

    psnet.ahrq.gov/web-mm/deadly-duo
    April 28, 2021 - The Deadly Duo Citation Text: Maldonado JR. The Deadly Duo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73153/psn-pdf
    April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough April 28, 2021 Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough Disclosure of Relev…
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